SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPU L ATION   Berrin...
GAZI  UNIVERSITY FACULTY OF MEDICINE
 
Background <ul><li>S urveys and meta-analysis concerning the management of PDPH in the obstetric population  have been  pu...
Aim <ul><li>Primarily to determine the current practice in the management of PDPH in a small sample reflecting roughly the...
Methods <ul><li>Q uestionnaire including  24  questions  similar to  Baraz and Collis’s   were given to the participants <...
Questionnaire
Results <ul><li>78 out of  111 surveys returned  </li></ul><ul><li>(R esponse rate  was  70% ) </li></ul><ul><li>The respo...
Results <ul><li>Rate of  audit ing  inadvertent dural puncture during labour or cesarean was 35% </li></ul><ul><li>H aving...
Prophylactic measures to prevent PDPH following recognized accidental dural puncture <ul><li>During delivery  </li></ul><u...
Results - During delivery <ul><li>When accidental dural puncture during epidural insertion was recognized  </li></ul><ul><...
Possible reasons for  using an epidural catheter as an  intrathecal catheter   <ul><li>No recommendation  (62%) </li></ul>...
Results - After delivery   Non-invasive methods for PDPH   treatment <ul><li>In addition to the encouragement of fluid int...
Ambulation  after delivery following  accidental dural puncture <ul><li>A s early as possible :  7% </li></ul><ul><li>Bed ...
Methods routinely used for PDPH   treatment <ul><li>1st option is the c onservative treatment  </li></ul><ul><li>Blood pat...
<ul><ul><li>History  ( Gormley 1960, DiGiovanni & Dunbar 1970 ) </li></ul></ul><ul><ul><li>Mechanism of action </li></ul><...
EBP <ul><li>Contraindications  </li></ul><ul><li>Infection on the back </li></ul><ul><li>Sepsis </li></ul><ul><li>Coagulop...
EBP <ul><li>C omplication rate is rare  </li></ul><ul><li>~ 35% backache </li></ul><ul><li>S uccess rate is  ~ 94%  (70-98...
Treatment <ul><li>I t is recommended  not to  delay EBP more than 24 h after the diagnosis of  severe  PDPH  </li></ul>
EBP <ul><li>Mostly performed in the recovery room </li></ul><ul><li>Sometimes in the labour ward </li></ul><ul><li>Rarely ...
EBP <ul><li>Intravenous access before EBP (69%) </li></ul><ul><li>ECG (58%)  </li></ul><ul><li>Blood pressure (65%) and  <...
Advices at discharge after a successfull EBP <ul><li>Discharge  </li></ul><ul><ul><li>After EBP 1 (4%), 2 (15%) or 3-6 hou...
After an unsuccessfull EBP <ul><li>Rate of never considering another EBP (36%)  </li></ul><ul><li>Rate of repeating EBP (3...
Conclusion <ul><li>According to the present survey, re-siting epidural catheter at a different intervertebral space or usi...
Conclusion <ul><li>Although these results showed the current practice of this small sample, in order to follow the change ...
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SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPULATION SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPULATION

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SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPULATION SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPULATION

  1. 1. SURVEY OF TURKISH PRACTICE EVALUATING THE MANAGEMENT OF POSTDURAL PUNCTURE HEADACHE IN THE OBSTETRIC POPU L ATION Berrin Günaydın, MD, PhD Department of Anesthesiology Gazi University Faculty of Medicine ANKARA-TURKEY
  2. 2. GAZI UNIVERSITY FACULTY OF MEDICINE
  3. 4. Background <ul><li>S urveys and meta-analysis concerning the management of PDPH in the obstetric population have been published </li></ul><ul><ul><li>Choi et al. Examining the evidence in anaesthesia literature: a survey and evaluation of obstetrical Postdural puncture headache reports. Can. J. Anesth., 49 , 49–56, 2002. </li></ul></ul><ul><ul><li>Baraz and Collis . The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia, 60 , 673-679, 2005. </li></ul></ul>
  4. 5. Aim <ul><li>Primarily to determine the current practice in the management of PDPH in a small sample reflecting roughly the commonly preferred approaches </li></ul><ul><li>S econdly to provide awareness of the responders with this particular entity </li></ul>
  5. 6. Methods <ul><li>Q uestionnaire including 24 questions similar to Baraz and Collis’s were given to the participants </li></ul><ul><li>Participants were asked to submit their surveys either to the surveyors or send it via e-mail to the contact person later </li></ul><ul><li>Microsoft Excel® software was used for data analysis </li></ul><ul><li>Results were presented as n and/or % </li></ul>
  6. 7. Questionnaire
  7. 8. Results <ul><li>78 out of 111 surveys returned </li></ul><ul><li>(R esponse rate was 70% ) </li></ul><ul><li>The responders consisted of </li></ul><ul><ul><li>21 (26.92%) residents </li></ul></ul><ul><ul><li>25 (32.05%) fellows </li></ul></ul><ul><ul><li>21 (26.92%) academic staff </li></ul></ul><ul><ul><li>11 (14.10%) did not identify any degree </li></ul></ul>
  8. 9. Results <ul><li>Rate of audit ing inadvertent dural puncture during labour or cesarean was 35% </li></ul><ul><li>H aving written guidelines for the management of accidental dural puncture </li></ul><ul><ul><li>Yes: 10% </li></ul></ul><ul><ul><li>N: 64% </li></ul></ul><ul><ul><li>U nder the process of writing : 4% </li></ul></ul><ul><ul><li>No reply : 22% </li></ul></ul>50% stated that it was necessary at the end of the survey
  9. 10. Prophylactic measures to prevent PDPH following recognized accidental dural puncture <ul><li>During delivery </li></ul><ul><li>No thing ( 19.2% ) </li></ul><ul><li>Others (80.8%)* </li></ul><ul><ul><li>Leave spinal catheter for 24 h </li></ul></ul><ul><ul><li>Avoid pushing </li></ul></ul><ul><ul><li>Variable </li></ul></ul><ul><ul><li>Limit 2nd stage </li></ul></ul><ul><li>After delivery * </li></ul><ul><li>F luid intake and/or p aracetamol/NSAID/codeine (59 -81 %) </li></ul><ul><li>Blood injection before catheter removal (10%) </li></ul><ul><li>Epidural c rystalloid infusion before catheter removal (19%) </li></ul><ul><li>Prophylactic blood patch within 24 h of delivery (12%) </li></ul><ul><li>Variable (15%) </li></ul>* one or more of the options have been chosen
  10. 11. Results - During delivery <ul><li>When accidental dural puncture during epidural insertion was recognized </li></ul><ul><ul><li>epidural catheter was left in situ to use as a spinal catheter (36%) </li></ul></ul><ul><li>Kuczkowski K.M., Decreasing the incidence of post-dural puncture headache: an update. Acta Anaesthesiol. Scand., 49, 594, 2005. </li></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>e pidural catheter was re-sited at a different level (64%) </li></ul></ul><ul><li>Gunaydin and Karaca . Prevention strategy for PDPH. Acta Anaesth. Belg., 57, 163-165, 2006. </li></ul>
  11. 12. Possible reasons for using an epidural catheter as an intrathecal catheter <ul><li>No recommendation (62%) </li></ul><ul><li>Possible reasons according to preferance order (38%)* </li></ul><ul><ul><li>Allow immediate analgesia for labour </li></ul></ul><ul><ul><li>Avoid another dural puncture </li></ul></ul><ul><ul><li>Reduce the incidence and/or severity of PDPH </li></ul></ul><ul><ul><li>Only in difficult cases ( e.g. obesity & multiple attempts ) </li></ul></ul><ul><li>Kuczkowski K.M., Post-dural puncture headache in the obstetric patient: an old problem. New solutions. Minerva Anestesiol., 70, 823-830, 2004. </li></ul><ul><li>Kuczkowski and Benumof . Decrease in the incidence of post-dural puncture headache: maintaining CSF pressure. Acta Anaesthesiol. Scand., 47, 98-100, 2003. </li></ul>* one or more of the options have been chosen
  12. 13. Results - After delivery Non-invasive methods for PDPH treatment <ul><li>In addition to the encouragement of fluid intake and/or p aracetamol/NSAID/codeine </li></ul><ul><ul><li>Caffeine (oral/iv) </li></ul></ul><ul><ul><li>Theophylline (oral) </li></ul></ul><ul><ul><li>IV hydrocortisone </li></ul></ul><ul><ul><li>IM ACTH </li></ul></ul><ul><ul><li>SC sumatriptin </li></ul></ul><ul><ul><li>Strong opioids </li></ul></ul>
  13. 14. Ambulation after delivery following accidental dural puncture <ul><li>A s early as possible : 7% </li></ul><ul><li>Bed rest : 6 h (3%) , 12 h (15%) or 24 h (36%) </li></ul><ul><li>No idea : 49% </li></ul>
  14. 15. Methods routinely used for PDPH treatment <ul><li>1st option is the c onservative treatment </li></ul><ul><li>Blood patch was mostly preferred after failed conservative treatment </li></ul><ul><li>Blood patch as soon as PDPH diagnosed is less preferred </li></ul><ul><li>D ifferent measures can be selected </li></ul>
  15. 16. <ul><ul><li>History ( Gormley 1960, DiGiovanni & Dunbar 1970 ) </li></ul></ul><ul><ul><li>Mechanism of action </li></ul></ul><ul><ul><ul><li>Plug theory </li></ul></ul></ul><ul><ul><ul><li>C lot is formed by injecting  1 5 -20 m l autologous blood in the epidural space to provid e adherence to the dura mater and directly patch es the hole </li></ul></ul></ul><ul><ul><ul><li>Pressure patch hypothesis </li></ul></ul></ul><ul><ul><ul><li>V olume of blood injected into epidural space increases CSF pressure leading to reduction in the traction of the pain sensitive brain structures </li></ul></ul></ul>Epidural Blood Patch ( EBP )
  16. 17. EBP <ul><li>Contraindications </li></ul><ul><li>Infection on the back </li></ul><ul><li>Sepsis </li></ul><ul><li>Coagulopathy </li></ul><ul><li>Raised white cell count </li></ul><ul><li>Prexia </li></ul><ul><li>Patient refusal </li></ul><ul><li>Timing </li></ul><ul><li>B eyond 24 h after dural puncture </li></ul><ul><li>R ecumbent positioning </li></ul><ul><li>For 2 h after patching may improve the efficacy </li></ul>
  17. 18. EBP <ul><li>C omplication rate is rare </li></ul><ul><li>~ 35% backache </li></ul><ul><li>S uccess rate is ~ 94% (70-98%) </li></ul><ul><ul><li>90% initial relief </li></ul></ul><ul><ul><li>61-75% persistent relief </li></ul></ul><ul><li>Repeat EBP has a similar success rate </li></ul><ul><li>R everse compl i cations of dural pu n cture </li></ul>
  18. 19. Treatment <ul><li>I t is recommended not to delay EBP more than 24 h after the diagnosis of severe PDPH </li></ul>
  19. 20. EBP <ul><li>Mostly performed in the recovery room </li></ul><ul><li>Sometimes in the labour ward </li></ul><ul><li>Rarely in the patient’s room </li></ul><ul><li>Generally performed with the help of a resident or a staff member </li></ul><ul><li>Rarely performed by one person </li></ul>Gunaydin et al. Acta Anaesthesiol Belg 2008
  20. 21. EBP <ul><li>Intravenous access before EBP (69%) </li></ul><ul><li>ECG (58%) </li></ul><ul><li>Blood pressure (65%) and </li></ul><ul><li>Pulse oxymeter (63%) were performed by the majority of the responders </li></ul>Gunaydin et al. Acta Anaesthesiol Belg 2008
  21. 22. Advices at discharge after a successfull EBP <ul><li>Discharge </li></ul><ul><ul><li>After EBP 1 (4%), 2 (15%) or 3-6 hours (44%) </li></ul></ul><ul><li>Follow-up </li></ul><ul><ul><li>Before full mobilization 2 (47%) or 4 hours (23%) of bed rest </li></ul></ul><ul><ul><li>Increase fluid intake </li></ul></ul><ul><ul><li>Keep intervention side clean </li></ul></ul><ul><ul><li>Contact whenever headache reoccurs and report fever, weakness or numbness </li></ul></ul>Gunaydin et al. Acta Anaesthesiol Belg 2008
  22. 23. After an unsuccessfull EBP <ul><li>Rate of never considering another EBP (36%) </li></ul><ul><li>Rate of repeating EBP (37%) </li></ul><ul><li>No recommendation (27%) </li></ul><ul><li>If two EBPs were unsuccessfull, further investigations were considered (63%) </li></ul>Gunaydin et al. Acta Anaesthesiol Belg 2008
  23. 24. Conclusion <ul><li>According to the present survey, re-siting epidural catheter at a different intervertebral space or using epidural catheter as an intrathecal catheter was preferred for the prevention of PDPH in case of recognized accidental dural puncture </li></ul><ul><li>N on - i n vasive methods consisting of encouragement of fluid intake and drugs were routinely used for the treatment of PDPH </li></ul>
  24. 25. Conclusion <ul><li>Although these results showed the current practice of this small sample, in order to follow the change in these strategies and to catch almost a standard approach for the prevention and management of PDPH , further surveys including most of the centers are required. </li></ul>
  25. 26. Thank you

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